This month, the first wave of locally-transmitted Zika virus infections in the continental United States in Florida could signal the escalation of a public health crisis with lasting consequences. Early action by the Obama administration improved access to Zika preventives, such as mosquito repellant, for Medicaid beneficiaries. Yet Medicaid’s effectiveness to fight against Zika is hobbled by the refusal of many state governments to close the Medicaid coverage gap. Tens of thousands of those most at risk for Zika in states like Florida, Texas, and Georgia are uninsured because they’re stuck in that gap.

State health advocates have keenly noted the hypocrisy: at the same time that state officials are calling on the federal government to address Zika with emergency aid, these same states cite opposition to federal support as a key reason to resist closing the Medicaid coverage gap—which would make health care accessible for hundreds of thousands of people in need. The result is billions of federal dollars left on the table in non-expansion states – money that would ensure a more comprehensive approach to fighting Zika than relying solely on emergency funds after the situation worsens.

Florida health advocates bristled at the governor’s suggestion that women thinking of becoming pregnant should consult their health care providers about the risk of Zika. Florida CHAIN released a statement  emphasizing the absurdity of this advice for the more than 280,000 uninsured Florida women caught in the coverage gap. The Florida Health Alliance created a Zika fact sheet and this week called on members to contact their legislators about Zika.

Puerto Ricans migrating to the mainland United States are also highly at risk. Puerto Rico recently declared a state of emergency on the island due to Zika. The lack of health care in migrant and immigrant communities has concerning implications for health equity in Florida. This disturbing disparity could be alleviated if Governor Scott and other Florida policymakers took swift action to close the coverage gap this year.

As Texas braces itself to be the next state with local transmissions of Zika, advocates are already calling on state policymakers to close the coverage gap as part of the equation to address Zika. They believe waiting until Zika becomes an emergency to take action is the wrong choice for the roughly 800,000 uninsured Texans in the coverage gap. Increased access to Medicaid among low-income individuals is critical to efforts to detect and prevent the spread of Zika and associated health problems such as microcephaly, which will have long-term effects. Although pregnant women typically have more generous eligibility for Medicaid, women who might not know they are pregnant yet, and the partners of pregnant women – who can spread Zika through sexual transmission – often fall into the coverage gap.

Meanwhile, Louisiana’s newly expanded Medicaid program, Healthy Louisiana, took swift action to prevent Zika by covering mosquito repellant and other preventive services. Louisiana’s decision to close the coverage gap effective July 1, 2016 means that 375,000 Louisianans are newly eligible for Medicaid coverage as Zika heats up in the region. What a contrast!

Without a doubt the biggest health policy/politics story of last week was Aetna’s announced pullout from a large number of ACA markets. Predictably, the announcement was greeted with pronouncements of doom for the ACA. You might think that people who have been predicting disaster since 2010 and have been wrong every time would be a little more circumspect by now. Silly you.

Let's separate the reality from the political spin. A number of factors are contributing to the related phenomena of premium rate increases and carrier market exit. First, the marketplace risk pool is smaller, older and sicker than many analysts anticipated – not always for bad reasons. For example, fewer employers are dropping coverage than CBO expected, making the universe of people eligible for marketplace plans smaller. Other factors driving utilization in the marketplace plans include pent-up demand from the previously uninsured, the extension of certain non ACA-compliant plans that has kept what is likely to be a healthier population out of the ACA marketplace, and the gradual phase-in of the individual mandate, which has probably led some people to decide that going uninsured is still a better deal economically. Congressional efforts to undermine the ACA's risk stabilization programs have not helped either. And two of those programs are expiring in the next year, leading to a one-time premium bump.

In the case of Aetna, there are carrier-specific factors at work, as well. In particular, there seems to be a link between the prospects for Aetna's merger with Humana and its decision to pull out of the marketplaces. In a July letter to the Department of Justice (DOJ), Aetna warned if the merger was blocked, it would pull back on its marketplace participation. The announcement of the pullback came shortly after DOJ sued to block the merger. If you are a complete cynic, you would see this move as either retribution or, at best, a negotiating ploy. It's probably closer to the truth to say the company expected to make a lot of money from the merger and needed some regulatory goodwill to pull it off. In the absence of that goodwill, and with the merger now in doubt, they became less willing to sustain losses in the ACA market.

An understanding of the underlying dynamics leads to the conclusion that some of the factors that are causing the current turbulence will simply abate over time, even if no action is taken. The noncompliant "grandmothered" plans will fade away after 2017, the individual mandate will increase and the pent-up demand will decline. Coupled with stepped up efforts to enroll more young adults, we can expect the ACA market risk pool to improve. Meanwhile, carriers that have gotten out of the game and shed their unfavorable risk are likely to come back in with more competitively priced plans.

At same time, ACA supporters should not be looking at recent developments through rose-colored glasses. At a minimum, plan pullouts and 2017 rate increases coming on the heels of co-op failures create a negative profile for the ACA at a politically sensitive moment. More importantly, these events underscore a structural weakness in the law. The marketplaces were designed to operate with a public option in order to guarantee both the universal availability of coverage and to create a cost-effective benchmark plan with a broad provider network against which private insurers would have to compete. While a great deal of energy was spent during the fight for passage debating the merits of the public option, not enough attention was paid to how to make sure the marketplaces worked properly in its absence. The co-ops were one half-hearted attempt, but they were always a weak reed that has now pretty much broken.

States still have a number of levers they could pull, including creating a state-based public option or requiring carriers to service the ACA market if they wanted to sell to other segments. However, that presumes the state government in question wants to make the ACA succeed – not at all a safe presumption. In fact, the very states that are probably going to have the hardest time with the recent market shifts are the ones least committed to the ACA’s success. Fixes at the federal level are technically pretty straight forward, but remain politically challenging with a Congress committed to repeal.

What this means is that in many places, the gradual stabilization of the ACA market will just have to play out over time. In the short run, unless the current or a subsequent administration can identify some fixes that lie within their current scope of regulatory authority, ACA performance will remain something of a self-fulfilling prophecy at the state level – succeeding where state administrations want it to succeed and struggling somewhat where they don't.

It's been a surprising electoral campaign in many respects, but from a health policy standpoint, what isn't happening is perhaps as surprising as what is happening. For the first election cycle since passage, the anti-ACA dog is barely barking. And while it is far too soon to take anything for granted, Secretary Clinton has opened up a substantial lead in the polls at a point in the campaign when polls begin to matter.

If Clinton does prevail in November, will it create an opening in Washington to build on the ACA and correct some its shortcomings? And will the opposition finally learn to love the ACA? Probably not (very probably not). First of all, there are very limited points of agreement between the two parties with respect to the ACA. Aside from agreement on repealing the "Cadillac tax" and bipartisan bills to reduce cost-sharing for people with chronic conditions, the two parties want to move health policy in very different directions, at least with respect to coverage. But even these limited points of agreement face headwinds in the form of disagreements about how to offset their cost to the treasury.

Secondly, bear in mind the GOP platform and the House Republican health care blueprint call for major cuts to Medicare and Medicaid that would reduce coverage and increase costs for millions of beneficiaries. If these 50-year-old programs are still in the crosshairs, why would the ACA to be any different? Finally, consider that the basic forces driving political polarization have not abated. So, while the "hot war" may subside a bit (fewer repeal votes), we can expect a health policy "Cold War" to continue until the basic political dynamics change or until one party or the other receives a new electoral mandate.

 

States to the Rescue?

While political gridlock continue to stymie progress on health policy in Washington, the same is not necessarily true in the states. It seems every week more evidence piles up on the benefits states reap from closing the Medicaid coverage gap. Last week was no exception. Recent studies highlight how closing the gap reduces uncompensated care, provides economic and fiscal benefits to states and improves the health and economic well-being of enrollees. At the same time, new evidence shows closing the gap does not lead to a spike in emergency room utilization, a concern often raised by opponents

And the political winds may also be shifting in favor of closing the gap, as both voters and local government officials lose patience with state inaction. With President Obama exiting the political arena, a Clinton win could set the stage for progress among the 19 holdouts that have not yet expanded coverage.

But state progress will not necessarily be limited to closing the gap. Other issues are also likely to get a fair share of attention. One big issue gaining ground in states is addressing surprise out-of-network bills. With the rise of narrow network plans both on and off ACA marketplaces, more and more people are finding themselves paying unexpected medical bills even when they try to stay within their health plan network. California's legislation addressing surprise out-of-network billing has a good chance of passing this year. But the issue has legs not only in blue states but in red states, too. Texas is considering steps to protect consumers from surprise bills. Progress in the two biggest states – with wildly disparate political environments – could prompt similar action across the country.

Two other state initiatives to watch are ballot measures in California and Colorado. The California proposal would reduce the amount some state programs have to pay for prescription drugs, while the more far-reaching Colorado measure would create a single-payer system in that state. Both measures face a tough road. Opponents are heavily outspending proponents, and the Colorado measure recently suffered a setback when a fiscal analysis found the revenue sources for the proposal were not adequate to cover the costs. But as long as lawmakers in Washington remain stuck in the political mud, we can expect states to keep pushing the boundaries in searching for solutions to our nation's pressing health care problems.

Transitioning between Medicaid and Marketplace coverage can create health care potholes for consumers, placing them in harm’s way. Transitioning coverage can be further complicated by challenges with health literacy and health insurance literacy – or understanding how to use health information to make informed health care decisions. Case in point: Connecticut.

July 31st marked the expiration of Connecticut’s Transitional Medicaid Assistance (TMA) option for parents whose Medicaid eligibility was reduced in the 2015 state budget. The transitional Medicaid program assists low-income families’ transition from Medicaid over one year. This experience shines light on two key issues facing consumers who transition between Medicaid and Marketplace coverage—understanding how to select and use health insurance and how to fit health insurance into family budget.

Why were these parents on TMA? In 2015, Connecticut reduced the Medicaid eligibility limit of parents from 201 to 155 percent Federal Poverty Level ($31,140 for a family of three). This resulted in “rollbacks” of parents from Medicaid to Marketplace eligibility. Affected were a small number of parents who were eligible for Medicaid through a category other than income, and the remaining parents who had become ineligible for Medicaid based on income and were poised to lose their coverage—about 14,000 parents. Connecticut Voices for Children led a successful advocacy campaign in 2015 to protect this group of parents from being dropped from Medicaid by highlighting parent’s legal access to Transitional Medicaid Assistance (TMA).

So how did it go? About 41 percent of those eligible enrolled in Marketplace plans, leaving over 8,000 uninsured. It also exposed a more complex set of issues.  Lingering problems remain for low-income consumers—health literacy and plan affordability. These are two longstanding pre-ACA factors that influence the success of a consumer-focused health agenda—not just in Connecticut, but in all states.   

Health-Literacy

Meeting consumers where they are….and sticking with them.

Connecticut’s effort to transition this group of parents from Medicaid to Marketplace coverage reveals the need for ongoing health literacy support. The literacy required to move from a public to private platform for health coverage is significant and can create confusion—even for veteran enrollment assistance workers. Health literacy is beyond understanding basic health insurance terminology—it is empowering consumers to be active partners in their health decision making, resulting in better health. In Connecticut, advocates supported this initial translation work through the development of their own flyers with clear, plain language instructions for low-income consumers. Advocates shared these resources broadly through their networks as a way to augment those of the Marketplace. Access Health CT also directed its energy and resources toward holding enrollment fairs.

While there are other initiatives to support health literacy underway in Connecticut, in some communities, the outreach and literacy work is largely unfunded. Over the long term, health literacy support and the advancement of broader goals around health improvement cannot be attained without dedicated resources.

Connecticut’s experience is an important reminder that if we really want to reach and improve the health of the “hard-to-reach,” we need assets inside communities to communicate an authentic message that inspires folks to enroll—and use their insurance coverage to improve their health. But is that enough? Even when community partners are heavily involved in outreach and enrollment efforts to aid with the transition, challenges still arise with helping consumers switch coverage in ways to allow them to continue accessing needed care.

Rhode Island illustrates that when you roll back the parent population from Medicaid to Marketplace coverage as they did in 2014, it is challenging to enroll consumers in coverage even with robust outreach and enrollment efforts. For parents, Marketplace plans are unfamiliar and have a more limited benefit package that lacks important supports like transportation and access to in-network clinics or providers.  Further, plans and networks are not aligned across platforms. Consumers’ knowledge of cost-sharing structures and risk-based insurance products offered in Marketplaces is limited. Additional support is needed to help consumers integrate private coverage into their household budget and access additional social service programs that address their financial stability beyond health care coverage. Community partners can play a key role in supporting consumers in this process, connecting them to existing networks of social service partners and working to ensure consumers have ongoing access to affordable, robust coverage.

The road ahead.

The long-term success in Connecticut will be measured during the next enrollment period when enrolled parents are asked to renew their Marketplace plans. Access Health CT understands the importance of assessing consumer experience. Over the coming months, it will conduct focus groups to learn what outreach strategies worked well and whether or not parents are utilizing their new plans. This will be important data to share with community partners so that all stakeholders can work together to improve consumer experience and support consumers in their effort to reach optimal health.

We have much work to do in protecting low-income consumers from high-cost coverage. High on the list are designing Marketplace products that meet the unique needs of low-income consumers and continuing to push for investment in outreach and enrollment and ongoing interactions between enrollers and consumers to promote increased health literacy for all.  As health system stakeholders pave the road for healthy communities, advocates can play a key role in ensuring consumers avoid health care potholes and have seamless access to needed services and supports to keep themselves and their families financially secure and healthy over the long run.

This week is National Health Center Week, but here at Community Catalyst we celebrate the impact of community health centers 52 weeks a year. Community health centers have traditionally been the primary source of care for underserved populations with the greatest health needs. They are at the forefront of providing culturally and linguistically competent services and have worked hard to win the trust of their diverse patient base. Many health centers have illustrated their commitment to health equity and their standing as trusted community touchpoints through their engagement in advocacy—including efforts to close the Medicaid coverage gap and the promotion of policies that improve health coverage for recent immigrant children.

Oftentimes low-income consumers realize they are ineligible for Medicaid coverage during their visits at community health centers. This link, along with a commitment to expanding health coverage for their patients, motivates community health centers and statewide health center organizations to participate in advocacy to close the coverage gap.

Community Health Centers Help Close the Gap

For example, the North Carolina Community Health Center Association has been a key part of the campaign to close the coverage gap in North Carolina for more than two years. With 357,000 North Carolinians stuck in the gap, putting a human face to the issue of health care access is critical. Through the Association, health advocates have connected with health centers, which have successfully leveraged relationships with local communities to aid story collection from consumers in the coverage gap as well as health care providers who typically see uninsured patients. 

National Health Center Week 2016

Over time, health centers and advocates have developed more effective ways of working together on story collection. North Carolina health advocates favor informal conversations with consumers and providers in the health center break rooms rather than formal sit-downs. Collecting stories this way creates fewer logistical burdens for staff and the more relaxed, comfortable environment lends itself to deeper conversations. These systems are made possible by the mutual partnership and trust developed between health advocates and health centers.

In Florida, health advocates working on closing the coverage gap have utilized similar partnerships with the Florida Association of Community Health Centers, Florida Council for Community Mental Health, and Florida Rural Health Association to collect stories for their “Lives on the Line” initiative, which features stories and photos of Florida consumers in the coverage gap. Advocates were able to collect photos and stories of people in the gap by setting up pop-up booths outside of community health centers in target areas across the state. The launch of the “Lives on the Line” website and social media activities featuring consumer stories brought renewed energy into Florida’s Close the Gap campaign while also serving to re-engage community health centers partners.

Community Health Centers are on the ‘Frontlines’ of Advocacy

The relationships Florida advocates built with health centers over the course of their multi-year Close the Gap campaign paved the way for story collection efforts focused on the KidCare Immigrant bill, which lifted the five-year waiting period for legal immigrant children to receive health coverage under Medicaid and the Children’s Health Insurance Program (CHIP). Advocates leveraged existing relationships with community health centers in predominantly Latino and immigrant communities to identify and collect compelling stories of the 17,000 immigrant children and their families that would be impacted by this policy. In part due to the humanization of the issue through personal storytelling, the bill was signed into law by Governor Scott in March 2016.

Participation in story collection for advocacy campaigns is just one way that community health centers engage on the ground with issues that affect the health of their client base. This National Health Center Week reminds us of how grateful we are for the important work and partnerships community health centers bring to health advocacy.

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We are encouraging everyone to participate in National Health Center Week 2016. To learn how you can be a part of it, please visit their page: National Health Center Week 2016 – Social Media Tools.